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Based on record review and staff interview, it was determined that the hospital failed to ensure that staff members responsible for each intervention were specifically identified in 7 of 8 Master Treatment Plans reviewed (A1, A3, A4, A5, A6, A7 and A8). This failure resulted in the patient and other staff being unaware of which staff person was assuming responsibility for the interventions being implemented.

Findings include:

Record review:

1. Patient A1 was admitted 5/24/13. The Master Treatment Plan was completed on 5/24/13. The responsible parties were not listed by name and credentials, but rather by discipline: "MD", "Nsg", and "PrTh (Primary Therapist LCSW)."

2. Patient A3 was admitted 5/24/13. The Master Treatment Plan was completed on 5/27/13. The responsible parties were not listed by name and credentials, but rather by discipline: "MD", and "Nsg."

3. Patient A4 was admitted 5/31/13. The Master Treatment Plan was completed on 5/31/13. The responsible parties were not listed by name and credentials, but rather by discipline: "MD", and "Nsg."

4. Patient A5 was admitted 5/16/13. The Master Treatment Plan was completed on 5/17/13. The responsible parties were not listed by name and credentials, but rather by discipline: "nursing staff, PrTh, and MD."

5. Patient A6 was admitted 5/27/13. The Master Treatment Plan was completed on 5/28/13. The responsible parties were not listed by name and credentials, but rather by discipline: "Nsg, MD, and PrTh."

6. Patient A7 was admitted 5/30/13. The Master Treatment Plan was completed on 5/31/13. The responsible parties were not listed by name and credentials but rather by discipline: "MD, RNs, LPNs, MHTs, LCSW, counseling staff, dietician, treatment team, and Nsg."

7. Patient A8 was admitted 5/7/13. The Master Treatment Plan was completed on 5/8/13. The responsible parties were not listed by name and credentials, but rather by discipline: "MD" and "Nsg."

Interview:

During an interview on 6/4/13 at 10:30, RN1 confirmed that responsible staff members were not identified by name and credentials for interventions listed in the Master Treatment Plan.

Based on record review, Hospital Policy review and staff interview this standard is not met for 3 of 8 sample patient records (A1, A3 and A8). The facility failed to update and document weekly treatment plan review notes per its own policy. This failure to update and document weekly Treatment Plan Reviews hinders the ability of the team to measure changes in the patient as a result of treatment interventions and may prolong hospital stays beyond the resolution of the behavior(s) requiring admission.

Findings include:

A. RECORD REVIEW:

1. Patient A1: Patient was hospitalized on 5/24/13. Master Treatment Plan (MTP) was completed on 5/24/13. The patient's first weekly (5/31/13) Treatment Plan review notes were absent in the patient's Medical Record.

2. Patient A3: Patient was hospitalized on 5/24/13. MTP was completed on 5/27/13. The patient's weekly (6/3/13) Treatment Plan Review notes were absent in the patient's Medical record.

3. Patient A8: Patient was hospitalized on 5/7/13. MTP was completed on 5/8/13. The patient's weekly (5/15, 5/22, 5/29) Treatment Plan Review notes were absent in the patient's Medical record.

B. POLICY REVIEW:

Hospital's "TREATMENT PLANNING" Policy, Created on 7/1/02 and Revised in May of 2013, states: "Following the initial completion of the MTP, weekly (no longer than 5 days) MTP conferences are held with each patient to discuss revisions in the patient's treatment plan. This will be documented on the Multidisciplinary Treatment Plan, and will be referenced in the staff progress notes. If there is no change in the treatment plan, that should also be documented." Further, "They will also document in their individual progress notes the changes in the treatment plan relevant to their specific disciplines, interventions and goals."

C. STAFF INTERVIEW:

In a meeting with Director of Social work on 6/4/13 at 10:30 am, the Director agreed that there were no corresponding progress notes in the medical records for Treatment Plan Reviews and "it is a deficiency."

In a meeting with the Medical Director on 6/4/13 at 2:30 pm, the Medical Director acknowledged and agreed that there were no corresponding progress notes for Treatment Plan Reviews per hospital policy.

In a meeting with the Nurse Surveyor and the Director of Nursing on 6/4/13 at 11 am, The Nursing Director confirmed the absence of corresponding progress notes in the medical records for Treatment Plan Reviews.

Based on Record review, Policy review and staff interview, the Medical Director failed to:

1. Assure that staff members responsible for each intervention were identified in 7 of 8 treatment plans (A1, A3, A4, A5, A6, A7 and A8). This failure can result in the patient and other staff being unaware of which staff person was assuming responsibility for the interventions being implemented. (Refer to B123)

2. Assure that the care provided followed hospital policy regarding treatment plan reviews, for 3 of 8 sample records reviewed (A1, A3, A8); there were no corresponding progress notes for weekly Treatment Plan Reviews as hospital policy specifies. This lack of documentation may lead to staff's inability to monitor changes in patient's treatment progress and possibly extend length of hospitalization unnecessarily. (Refer to B124)

Based on record review and interview, the Director of Nursing failed to:

1. Ensure that nursing staff responsible for nursing interventions were specifically identified in 7 of 8 Master Treatment Plans reviewed (A1, A3, A4, A5, A6, A7 and A8). This failure can result in the patient and other staff being unaware of which nurse was assuming responsibility for the interventions being implemented. (Refer to B123)

2. Ensure that nursing staff updated and documented weekly Master Treatment Plan reviews related to patient goals and nursing interventions in 3 of 8 records reviewed. This failure to update and document any changes needed in the Master Treatment Plan hinders the ability of the team to measure changes in the patient's progress and may prolong hospital stay. (Refer to B124)